| NPI | 1548935117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: OR 202210002NP-PP) |
| Additional Taxonomies | 363L00000X Nurse Practitioner (Licence: NY 348094) |
| Enumeration Date | 2021-08-15 |
| Last Update Date | 2023-03-07 |